Many doctors are disturbed they will be paid less 鈥� often a lot less 鈥� to care for the millions of patients projected to buy coverage through the health law鈥檚 new insurance marketplaces.
Some have complained to medical associations, including those in New York, California, Connecticut, Texas and Georgia, saying the discounted rates could lead to a two-tiered system in which fewer doctors participate, potentially making it harder for consumers to get the care they need.
鈥淎s it is, there is a shortage of primary care physicians in the country, and they don鈥檛 have enough time to see all the patients who are calling them,鈥� said Peter Cunningham, a senior fellow at the nonpartisan Center for Studying Health System Change in Washington D.C.
If providers are paid less, 鈥渁re [enrollees] going to have difficulty getting physicians to accept them as patients?鈥�
Insurance officials acknowledge they have reduced rates in some plans, saying they are under enormous pressure to keep premiums affordable. They say physicians will make up for the lower pay by seeing more patients, since the plans tend to have smaller networks of doctors.
But many primary care doctors say they barely have time to take care of the patients they have now.聽
The conflict sheds light on the often murky world of insurance contracts in which physicians don鈥檛 always know which plans they鈥檙e listed in or how much they鈥檙e being paid to treat patients in a particular plan. As a result, some doctors are just learning about the lower pay rates in some plans sold in the online markets, or exchanges
鈥淚f you鈥檙e a physician and you鈥檝e negotiated a rate from insurance, shouldn鈥檛 it be the same on or off the exchange?鈥� said Matthew Katz, executive vice president of the Connecticut State Medical Society. 鈥淵ou鈥檙e providing the same service.鈥�
Blues: No Desire 鈥楾o Gouge鈥� Docs
A senior executive at Blue Cross Blue Shield Association said some of its 37 member organizations 鈥� each of which operate independently and offer a variety of plans 鈥� are offering lower rates to physicians in smaller exchange plan networks.聽
But, she said, plans know that a good network of providers is essential or customers 鈥渨ill go someplace else,鈥� and they are enlisting sufficient numbers of doctors.
鈥淲e鈥檙e not motivated to gouge the doctor,鈥� said Kim Holland, Blue Cross Blue Shield Association executive director for state affairs. 鈥淲e depend on good relationships with quality physicians. 鈥� I can鈥檛 imagine any product we offer is going to have a physician rate that would discourage them from seeing a patient.鈥�
But some physicians see things differently. Contracts between insurers and doctors vary with some allowing insurers to adjust rates unilaterally or to assign a doctor to multiple plans.
鈥淚鈥檝e participated with Oxford since 1985. They don鈥檛 send me a contract every year to sign. They don鈥檛 send me the rates. You don鈥檛 know the rates,鈥� said Dr. Paul Orloff, a physician who is president of the New York County Medical Society. 鈥淚t鈥檚 the only game in town so you sign. They have a right to unilaterally change the rates at any time during the contract.鈥�
The benchmark for physician fees is the rate the federal government sets for services provided to older Americans through Medicare. In many markets, commercial plans may pay slightly above the Medicare rates, while doctors say that many of the new exchange plans are offering rates below that.
Physicians are uncomfortable discussing their rates because of antitrust laws, and insurers say the information is proprietary. But information cobbled together from interviews suggests that if the Medicare pays $90 for an office visit of a complex nature, and a commercial plan pays $100 or more, some exchange plans are offering $60 to $70. Doctors say the insurers have not always clearly spelled out the proposed rate reductions.
Some experts minimized the impact of lower pay rates on enrollees.
People 鈥渕ay experience wait times to get in, but that is not unique to people in exchange plans,鈥� said Sara Rosenbaum, a professor of health law and policy at George Washington University,
Rosenbaum said she was not overly concerned about physicians鈥� compensation. 鈥淚 don鈥檛 mean to suggest that physicians don鈥檛 deserve to do well,鈥� she said. 鈥淏ut physicians are very well-compensated people, no matter what.鈥�
Confusion About Rates, Provider Lists
Many doctors say they have not decided if they will participate in the new plans 鈥搃n some cases, even when an insurer is including them in their provider list.
A survey by The Medical Society of the State of New York found that 40 percent of more than 400 physicians who had responded so far said they chose not to participate in a health insurer鈥檚 exchange plan, and one-third said they did not know whether they were participating or not.
Two-thirds indicated they had received no information about reimbursements; of those who did ge that information, 鈥渁 significant majority indicated that the reimbursement generally was well below what the insurer pays in other contracts,鈥� according to a statement from the society鈥檚 president Dr. Sam Unterricht.
鈥淚 have patients calling my office and saying 鈥� 鈥極h good, I see you鈥檙e in the network,鈥欌�� said Patricia McLaughlin, an ophthalmologist in New York City. But, she added, 鈥淚鈥檓 not sure I am or am not at this point.鈥�
Some insurers have contractual arrangements with physicians that allow them to automatically include doctors in a new plan, unless the physician requests to opt out in writing, according to Mike Scribner, CEO of Strategic Healthcare Partners, a health care consulting firm based in Savannah, Ga., that represents about 700 physicians and 30 managed care hospitals in the state.
Doctors say the Blue Cross Blue Shield Association plans have generally been more straightforward about the discounted rates 鈥揳nd some doctors who had the opportunity to 鈥渙pt out鈥� of their exchange plans did so.
Dr. Richard E. Thorp, an internist who is president of the California Medical Association and heads a physician-owned multi-specialty primary care group in Paradise, Calif., said one plan sold on that exchange 鈥渨as going to pay us significantly less for doing that business. And we are already very busy.鈥�
His practice delayed signing a contract, he said. But about three weeks ago, the group was informed the insurer was short on physicians and was therefore including doctors from other plans at their old rates.聽 So his practice was included at the higher rate.
Advocates say that consumers should be wary of information in plan directories and confirm participation with their doctors.
The California Medical Association is so concerned about errors that it has asked Covered California, the state鈥檚 insurance marketplace, to remove a search function that lets buyers plug in the names of physicians and get a list of all the plans that they participate in, said Lisa Folberg, vice president for medical and regulatory policy for the California Medical Association.
鈥淭here shouldn鈥檛 be any ambiguity about who鈥檚 in the network,鈥� said Lynn Quincy, a senior analyst with Consumers Union, the policy division of Consumer Reports.
鈥淭hese consumers are buying a product, one dimension of which is to provide a network鈥揳 very important dimension.鈥澛�